HIV protease inhibitor combinations

ABSTRACT

Combinations of certain HIV-1 protease inhibitors are provided which effectively inhibit the HIV-1 protease enzyme while eliminating or substantially reducing the viral cross-resistance seen with use of individual HIV-1 protease inhibitors. Such combinations are useful in the treatment of diseases associated with the AIDS virus.

CROSS REFERENCE TO RELATED APPLICATIONS

This is a continuation-in-part of our pending U.S. patent applicationSer. No. 08/270,614 filed Jul. 5, 1994, which is a continuation-in-partof our U.S. patent application Ser. No. 07/79,978 filed Jul. 31, 1987,now U.S. Pat. No. 4,987,228, issued on Jan. 22, 1991, which parentapplication is hereby incorporated by reference in its entirety.

BACKGROUND OF THE INVENTION

The present invention relates to combinations of antiviral agents. Moreparticularly, it relates to combinations of HIV-1 protease inhibitorswhich exhibit lack of cross-resistance and are thus desirable in theclinical treatment of HIV infection.

Human Immunodeficiency Virus (HIV-1) is the causative agent of AcquiredImmunodeficiency Syndrome (AIDS) in man. There are currently only threedrugs approved for the treatment of HIV infection in the United States,AZT (zidovudine; Retrovir®), DDI (didanosine, Videx®) and DDC(zalcitabine, Hivid®). All three are members of the nucleoside analogclass which inhibit the activity of the HIV-1 reverse transcriptaseenzyme. These nucleoside analogs have shown efficacy in the clinicalsetting. However, none of them appear to halt disease progression, andtreatment, particularly with AZT, results in viral variants that havesignificantly reduced drug sensitivity.

The HIV-1 reverse transcriptase has proven to be a very accommodatingenzyme that is capable of harboring several amino acid substitutionsthat render it resistant to individual nucleoside analogs or acombination of nucleoside and/or non-nucleoside analogs.

HIV-1 also encodes an aspartyl protease enzyme that plays an essentialrole in reproduction of the virus late in infection and represents anattractive target for drug intervention. Recently, several inhibitors ofthis protease have been reported in the literature. Since these proteaseinhibitors, unlike reverse transcriptase inhibitors, have the ability toinhibit the production of infectious virus particles inchronically-infected cells, they are promising candidates for anti-HIVtherapy.

Our parent U.S. application Ser. No. 07/79,978 filed Jun. 25, 1993describes novel aminediol HIV-1 protease inhibitors of the followingformula I ##STR1## where A^(a), A^(b) and A^(c) are independently:

(1) hydrogen;

(2) alkyl, especially lower alkyl; ##STR2## D^(a) and D^(b) areindependently selected from groups of the formula: ##STR3## where D^(a)and D^(b) are bonded to the groups A^(a) and A^(b), respectively,through the moiety --E--N(R⁸)--, where E is a single bond or a peptidechain containing 1 to 4 amino acids, the N-terminus of which is bondedto A^(a) when E is part of D^(a) or to A^(b) when E is part of D^(b) ;

R¹ and R² are independently:

(1) hydrogen;

(2) alkyl, especially lower alkyl;

(3) alkenyl, especially lower alkenyl;

(4) aryl;

(5) heterocyclo; or

(6) carbocyclo, such as cycloalkyl;

R³ and R⁴ are independently:

(a) hydrogen;

alkyl, especially lower alkyl;

(c) aryl;

(d) heterocyclo;

(e) carbocyclo, such as cycloalkyl;

(f) when R³ and R⁴ are bonded to a common nitrogen atom, R³ and R⁴ maybe joined, together with that nitrogen atom, to form a heterocyclic ringsystem, such as a 5 to 7 membered heterocyclic ring; or

(g) when E is a single bond and R³ is part of A^(a) or A^(b), R³ may,together with R⁸, form an alkylene group, for example, having one tofive carbons, such as wherein R³ and R⁸, together with the atoms towhich they are bonded, form the cyclic moiety: ##STR4## R⁵, R⁶ and R⁷are independently: (a) hydrogen;

(b) alkyl, especially lower alkyl;

(c) aryl;

(d) carbocyclo, such as cycloalkyl;

(e) fluorenyl;

(f) heterocyclo;

(g) R⁵, R⁶ and R⁷ may, independently, be joined, together with thecarbon atom to which they are bonded, to form a mono-, bi- or tricycliccarbocyclic ring system, especially wherein each ring contains 3 to 7carbon atoms, or a mono-, bi- or tricyclic heterocyclic ring system;

(h) alkynyl;

(i) alkenyl; or

(g) when E is a single bond and R⁵, R⁶ and R⁷ are part of A^(a) orA^(b), one of R⁵, R⁶, or R⁷ may, together with R⁸, form an alkylenegroup, for example, having one to three carbons, such as wherein R⁵ andR⁶ are methyl and R⁷ and R⁸, together with the atoms to which they arebonded, form the cyclic moiety: ##STR5## R⁸ is: (a) hydrogen;

(b) alkyl, especially unsubstituted lower alkyl or aryl-lower alkyl;

(c) R⁸ and R⁹ may be joined, together with the atoms to which they arebonded, to form a heterocyclic ring system, for example, a 5 to 7membered monocyclic heterocyclic ring;

(d) R⁸ may be joined together with R⁵, R⁶ or R⁷ as described above;

(e) R⁸ may be joined together with R³ as described above; or

(f) R⁸ and R¹¹ may be joined, together with the atoms to which they arebonded, to form a heterocyclic ring system, such as where R⁸ and R¹¹together are an alkylene group;

R⁹ and R^(9') are independently:

(a) hydrogen;

(b) alkyl, especially lower alkyl;

(c) alkenyl, especially lower alkenyl;

(d) alkynyl;

(e) aryl

(f) heterocyclo;

(g) carbocyclo, such as cycloalkyl;

(h) R⁹ may be joined together with R⁸ as described above; or

(i) R⁹ and R^(9') may be joined, together with the carbon atom to whichthey are bonded, to form a carbocyclic group, such as 5- or 6-memberedcarbocyclic ring;

R¹⁰ is:

(a) hydrogen;

alkyl, such as unsubstituted lower alkyl or hydroxy-lower alkyl,cycloalkyl-lower alkyl, aryl-lower alkyl or heterocyclo-lower alkyl;

(c) alkenyl, especially lower alkenyl;

(d) alkynyl;

(e) carbocyclo, such as cycloalkyl;

(f) aryl; or

(g) R^(l0) and R¹¹ taken together may form a bond to give a keto (C═O)group;

R¹¹ is:

(a) hydrogen;

(b) a hydroxyl protecting group, such as alkyl;

(c) R¹¹ may be joined together with R⁸ as described above; or

(d) R¹¹ may, together with R¹⁰, form a bond to give a keto group asdescribed above;

Z is oxygen or sulfur; and p and q are, independently, integers from 0to 4; and salts, preferably pharmaceutically acceptable salts, thereof.Among the compounds disclosed is[1S-[1R*,2S*(2S*,3R*)]]-[3-[[3-[[(1,1-dimethylethoxy)carbonyl]amino]-2-hydroxy-4-(4-[2-(4-morpholinyl)-2-oxo-ethoxy]phenyl]butyl]amino]-2-hydroxy-1-(phenylmethyl)propyl]carbamicacid, 1,1-dimethylethyl ester, the structure of which is as follows:##STR6## This compound will also be referred to below as BMS-186318.

Preferred embodiments of BMS-186318 include the pharmaceuticallyacceptable salts formed with inorganic and/or organic acids, e.g.succinic acid, acetic acid, hydrochloric acid, fumaric acid, citricacid, malic acid, methanesulfonic acid, benzenesulfonic acid, phosphoricacid, maleic acid and tartaric acid. The succinate salt of BMS-186318 isa particularly preferred embodiment.

EP 432695 A2 discloses the Hoffmann-LaRoche HIV-1 protease inhibitor ofthe formula ##STR7## which is known as saquinavir or Ro 31-8959. Thiscompound has the chemical nameN-tert.butyl-decahydro-2(2(R)-hydroxy-4-phenyl-3(S)-[[N-(2-quinolylcarbonyl)-L-asparaginyl)amino)butyl]-(4aS,8aS)-isoquinoline-3(S)-carboxamide.

PCT Published Application WO 92/08688 discloses the Monsanto-SearleHIV-1 protease inhibitor designated SC-52151 having the formula ##STR8##and the chemical name [1S-[1R*(R*), 2S*]]-N¹[3-[[[(1,1-dimethylethyl)amino]-carbonyl](2-methylpropyl)amino]-2-hydroxy-1-(phenylmethyl)propyl]-2-[(2-quinolinylcarbonyl)amino]-butanediamide.

EP 402646 A1 discloses the Abbott HIV-1 protease inhibitor designatedA-77003 having the formula ##STR9## and the chemical name(2S,3R,4S,5S)-2,5-di-(N-((N-methyl-N-((2-pyridinyl)methyl)amino)carbonyl)-valinyl-amino)-3,4-dihydroxy-1,6-diphenylhexane.

The Abbott HIV-1 protease inhibitor designated ABT-538 having theformula ##STR10## and the chemical name,[1S-(1R,2R,4R)]-N-[2-hydroxy-5-phenyl-1-(phenylmethyl)-1-[[(5-thiazolylmethoxy)carbonyl]amino]pentyl]-N²-[[N-methyl[[2-(1-methylethyl)-4-thiazolyl]methyl]amino]carbonyl]L-valinamide,is generically disclosed in EP 486948 A2 and specifically disclosed inan abstract for the 207th American Chemical Society meeting (Mar. 13-17,1994) held in San Diego, Calif.

EP 486948 A2 discloses the Abbott HIV-1 protease inhibitor designatedA-80987 having the formula ##STR11## and the chemical name(2S,3S,5S)-2-(N-(N-((2-pyridinyl)methoxycarbonyl)-valinyl)amino)-5-(N-((3-pyridinyl)methoxycarbonyl)amino)-1,6-diphenyl-3-hydroxyhexane.

EP 541168 A1 discloses the Merck HIV-1 protease inhibitor designatedL-735,524 having the formula ##STR12## and the chemical nameN-(2(R)-hydroxy-1(S)-indanyl)-2(R)-phenylmethyl-4(S)-hydroxy-5-(1-(4-(3-pyridylmethyl)-2(S)-N'-(t-butylcarboxamido)-piperazinyl))-pentaneamide.

The Agouron HIV-1 protease inhibitor designated AG-1343 having theformula ##STR13## and the chemical name[3S-[2(2S*,3S*)3a,4ab,8ab]]-N-(1,1-dimethylethyl)decahydro-2-[2-hydroxy-3-[(3-hydroxy-2-methylbenzoyl)amino]-4-(phenylthio)butyl]-3-isoquinolinecarboxamidewas disclosed, for example, by V. Kalish of Agouron at the 1st WinterBioorganic/Medicinal Chemistry Symposium held at Steamboat Springs,Colorado on January 29-Feb. 2, 1995 (see also, Rev. Med. Virol. 5:23-33, 1995).

AG-1343 may be prepared by reacting the amine of the formula ##STR14##(prepared as described in Jungheim, et al., European PublishedApplication 604,185A1) with the acid ##STR15## (prepared as described inU.S. Pat. No. 5,110,979; Houbion, et al. in Org. Prep. Proced. Int.,1979, 11, 27; and Cresp, et al., in J. Chem. Soc. Perkins Trans. I,1974, 2435) under standard peptide coupling conditions, e.g.1-(3-dimethylaminopropyl)-3-ethylcarbodiimide(EDC)/hydroxybenzotriazole(HOBT).

The above-described Hoffmann-LaRoche, Monsanto-Searle, Agouron, Abbottand Merck HIV-1 protease inhibitors have all been reported to be underclinical development for HIV infection.

Various suggestions have been made in the literature to combineantiviral drugs, including HIV protease inhibitors, with other antiviralagents (see, for example, Antimicrob. Agents Chemother. 36(3), 509-520,1992; J. Acquired Immune Deficiency Syndromes, 3 (Suppl. 2), S99-S103,1990; and J. Acquired Immune Deficiency Syndromes, 6, 162-170, 1993).PCT Application WO 94/02149 discloses the so-called convergentcombination approach to antiviral therapy whereby an antivirallyeffective amount of three or more different agents are employed, each ofwhich is capable of inhibiting the activity of the same gene product orgene of a virus.

Suppressing chronic HIV infection requires long-term therapy. We havefound that although the HIV virus appears to have more difficultybecoming resistant to protease inhibitors than to non-nucleoside reversetranscriptase inhibitors, resistance eventually does develop to HIVprotease inhibitors. In-vitro drug sensitivity assays on the HIV-1protease inhibitors currently in clinical trials have demonstratedunique resistance profiles, suggesting that combination of two or moreprotease inhibitors may be an effective approach to inhibiting HIVreplication.

It is an object of the present invention to provide certain combinationsof HIV-1 protease inhibitors which, when used either concurrently orsequentially, overcome the drug resistance seen with use of individualHIV-1 protease inhibitors or many combinations of HIV-1 proteaseinhibitors.

SUMMARY OF THE INVENTION

In one aspect this invention provides pharmaceutical compositions forprophylaxis or treatment of diseases caused by the HIV virus comprisingan effective HIV-inhibiting amount of BMS-186318 having the formula##STR16## or a pharmaceutically acceptable derivative thereof, and aneffective HIV-inhibiting amount of one or more HIV-1 protease inhibitorsselected from the group consisting of (a) Ro 31-8959 having the formula##STR17## or a pharmaceutically acceptable derivative thereof, (b)SC-52151 having the formula ##STR18## or a pharmaceutically acceptablederivative thereof, (c) A-77003 having the formula ##STR19## or apharmaceutically acceptable derivative thereof, (d) A-80987 having theformula ##STR20## or a pharmaceutically acceptable derivative thereof,(e) L-735,524 having the formula ##STR21## or a pharmaceuticallyacceptable derivative thereof, (f) ABT-538 having the formula ##STR22##or a pharmaceutically acceptable derivative thereof, and (g) AG-1343having the formula ##STR23## or a pharmaceutically acceptable derivativethereof, in combination with a pharmaceutically acceptable carrier ordiluent.

In another aspect the present invention provides a method for theprophylaxis or treatment of diseases caused by the HIV virus in a humanpatient, which comprises administering to said patient, eithersequentially or concurrently, an effective HIV-inhibiting amount ofBMS-186318 having the formula ##STR24## or a pharmaceutically acceptablederivative thereof, and an effective HIV-inhibiting amount of one ormore HIV-1 protease inhibitors selected from (a) Ro 31-8959 having theformula ##STR25## or a pharmaceutically acceptable derivative thereof,(b) SC-52151 having the formula, ##STR26## or a pharmaceuticallyacceptable derivative thereof, (c) A-77003 having the formula ##STR27##or a pharmaceutically acceptable derivative thereof, (d) A-80987 havingthe formula ##STR28## or a pharmaceutically acceptable derivativethereof, (e) ABT-538 having the formula ##STR29## or a pharmaceuticallyacceptable derivative thereof, (f) L-735,524 having the formula##STR30## or a pharmaceutically acceptable derivative thereof, and (g)AG-1343 having the formula ##STR31## or a pharmaceutically acceptablederivative thereof.

In yet another aspect the present invention provides a method forreducing or eliminating resistance resulting from administration of anHIV-1 protease inhibitor selected from the group consisting of (a) Ro31-8959, or a pharmaceutically acceptable derivative thereof, (b)SC-52151, or a pharmaceutically acceptable derivative thereof, (c)A-77003, or a pharmaceutically acceptable derivative thereof, (d)A-80987, or a pharmaceutically acceptable derivative thereof, (e)ABT-538, or a pharmaceutically acceptable derivative thereof, (f)L-735,524, or a pharmaceutically acceptable derivative thereof, and (g)AG-1343, or a pharmaceutically acceptable derivative thereof, or acombination of two or more of said inhibitors, which comprisesadministering either sequentially or concurrently, an effectiveHIV-inhibiting amount of BMS-186318, or a pharmaceutically acceptablederivative thereof.

DETAILED DESCRIPTION

Combination therapy has been proposed for treatment of antiviraldiseases, including diseases associated with AIDS. In our parentapplication Ser. No. 07/79978 filed Jun. 25, 1993, we disclosed that thenovel aminediol HIV-1 protease inhibitors of general formula I abovecould be used in combination with other antiviral agents, includingother HIV protease inhibitors.

We have now found that BMS-186318, included within the scope of generalformula I and specifically disclosed in Example 226 of our parentapplication, exhibits unexpected advantages when used in combinationwith certain other HIV-1 protease inhibitors. First, BMS 186,318displays a synergistic antiviral effect in cell culture assays when usedin combination with either Ro 31-8959 or SC-52151. Second, HIV-1variants resistant to BMS 186,318 remain susceptible to inhibition bythe other protease inhibitors. The surprising lack of cross-resistanceseen with these combinations would be an important clinical advance inthe treatment of diseases caused by HIV.

The term "a pharmaceutically acceptable derivative" as used herein ismeant to include any pharmaceutically acceptable salt, prodrug orsolvate of a compound of the present invention which, uponadministration to the host, is capable of providing (directly orindirectly) the parent compound or an antivirally effective metaboliteor residue thereof.

The term "pharmaceutically acceptable salt" as used herein denotespharmaceutically acceptable acidic salts formed with inorganic and/ororganic acids. Suitable pharmaceutically acceptable salts of the HIV-1protease inhibitor compounds of the present invention are disclosed inEP 580402 A2, EP 432695 A2, WO 92/08688, EP 402646 A1, EP 486948 A2 andEP 541168 A1. Illustrative of such salts are acid addition salts formedfrom inorganic acids such as hydrochloric acid, hydrobromic, nitricacid, sulfuric acid and phosphoric acid and organic acids such as oxalicacid, acetic acid, maleic acid, lactic acid, glycolic acid, tartaricacid, succinic acid, methanesulfonic acid and citric acid.

The term "solvate" is meant to include both hydrates and solvates withorganic solvents. Preferably, the solvates are hydrates.

Prodrugs of the HIV inhibitor compounds are also contemplated. The term"prodrug" as used herein denotes a compound which, upon administrationto a patient, undergoes chemical conversion by metabolic or chemicalprocesses to yield the parent compound, or a salt or solvate thereof.See H. Bundgaard, "Drugs of the Future", 16(5), 443-458 (1991) and H.Bundgaard(Ed.), "Design of Prodrugs", 1985 Elsevier (Amsterdam), bothincorporated herein by reference.

A method for preparing BMS-186318 is disclosed below in Example 1.Methods for preparing the other HIV-1 protease inhibitors encompassed bythe present invention are disclosed in the references disclosed above inconnection with pharmaceutically acceptable salts and with AG-1343.

The BMS-186318 and the other HIV-1 protease inhibitor(s) may beadministered either simultaneously (either separately or in combination)or sequentially. If administration is sequential, the delay inadministering the active ingredients should not be such as to lose thebenefit of the advantageous effect of the combination. Preferably,administration will be simultaneous.

Each compound is employed in the combination in an amount at which itexhibits HIV-inhibitory activity when used alone. Suitable dosage rangesare disclosed in the literature, e.g. see the patent referencesindicated above in connection with pharmaceutically acceptable salts.

For example, BMS-186318 may be administered in a total daily dosage offrom about 1 to 150 mg/kg of body weight, preferably about 10 to 50mg/kg of body weight. Ro 31-8959 may be administered in a daily dosageof from about 3 mg to about 3 grams, preferably about 10 mg to 1 gram.SC-52151 may be administered in a total daily dose of from about 0.001to 10 mg/kg body weight, preferably 0.01 to 1 mg/kg. A-77003 may beadministered in a daily dosage of from about 0.001 to 10 mg/kg,preferably 0.01 to 1 mg/kg of body weight. A-80987 may be administeredin a total daily dose of from about 0.001 to 300 mg/kg body weight,preferably 0.1 to 10 mg/kg. L-735,524 may be administered in a totaldaily dosage of from about 0.02 to 10 grams. ABT-538 may be administeredin a total daily dosage of from about 0.001 to 300 mg/kg of body weight.AG-1343 may be administered in a total daily dosage of from about 100 mgto 2000 mg.

It will be appreciated that the amount of a combination of the inventionrequired for use in treatment will vary not only with the particularcompounds selected but also with the route of administration, the natureof the condition being treated and the age and condition of the patientand, ultimately, will be at the discretion of the attendant physician.In general, however, a suitable daily dose will be in the range of fromabout 0.001 to about 300 mg/kg of body weight for each compound. Apreferred dosage range would be in the range of between about 1 andabout 50 mg/kg of body weight per day, administered as a single dose orin the form of individual divided doses, such as from 1-4 times per day.

The compositions of the present invention may be formulated, forexample, by employing conventional solid or liquid vehicles or diluents,as well as pharmaceutical additives of a type appropriate to the mode ofdesired administration. The compounds may, for example, be administeredorally, such as in the form of tablets, capsules, granules or powders;parenterally, such as by subcutaneous, intravenous, intramuscular orintrasternal injection or infusion techniques (e.g. as sterileinjectable aqueous or non-aqueous solutions or suspension); topically,such as in the form of ointments, creams or lotions, or as a transdermalpatch, or rectally such as in the form of suppositories; in dosage unitformulations containing non-toxic, pharmaceutically acceptable vehiclesor diluents. The compounds may, for example, be administeredliposomally.

When administered orally, the compositions may be prepared by techniqueswell-known in the art of pharmaceutical formulation. As a suspensionthey may, for example, contain microcrystalline cellulose for impartingbulk, alginic acid or sodium alginate as a suspending agent,methylcellulose as a viscosity enhancer, and sweeteners or flavoringagents known in the art. As immediate release tablets, the presentcompositions may contain microcrystalline cellulose, dicalciumphosphate, starch, magnesium stearate and/or lactose and/or otherexcipients, binders, extenders, disintegrants, diluents and lubricantsknown in the art.

When administered as injectable solutions or suspensions, the presentcompositions may be formulated according to techniques well-known in thepharmaceutical art, using suitable non-toxic, parenterally acceptablediluents or solvents, such as mannitol, 1,3-butanediol, water, Ringer'ssolution, an isotonic sodium chloride solution, or other suitabledispersing or wetting and suspending agents, including synthetic mono-or diglycerides and fatty acids, including oleic acid.

When rectally administered in the form of suppositories, thesecompositions may be prepared by techniques well-known in thepharmaceutical art by mixing the drug with a suitable non-irritatingexcipient, such as cocoa butter, synthetic glyceride esters orpolyethylene glycols, which are solid at ordinary temperatures, butliquify and/or dissolve in the rectal cavity to release the drug.

For topical administration to the epidermis, the compositions may beformulated as lotions, ointments or creams, or as a transdermal patch.Ointments and creams may, for example, be formulated with an aqueous oroily base with the addition of suitable thickening and/or gellingagents. Lotions may be formulated with an aqueous or oily base and willin general also contain one or more emulsifying agents, stabilizingagents, dispersing agents, suspending agents, thickening agents, orcoloring agents. Formulations suitable for topical administration to themouth include lozenges, comprising active ingredient in a flavored base,usually sucrose and acacia or tragacanth; pastilles containing theactive ingredient in an inert base such as gelatin and glycerin orsucrose and acacia; and mouthwashes comprising the active ingredient ina suitable liquid carrier.

The compositions of the present invention are useful in the inhibitionof HIV protease, and thus in the prevention and/or treatment ofinfections caused by HIV viruses (HIV-1, HIV-2, and mutants thereof),including the treatment of consequent pathological conditions such asAIDS.

Use of the compositions of the present invention in inhibiting HIVprotease includes, but is not limited to, treating a wide range ofstates of HIV infection such as treating or preventing AIDS or ARC (AIDSrelated complex), treating both symptomatic and asymptomaticHIV-infected patients, and treating actual or potential exposure to HIV.For example, the compositions of the present invention are useful intreating infection by HIV after suspected past exposure to HIV by, e.g.blood transfusion, accidental needle stick, or exposure to patient bloodduring surgery.

The following example illustrates the invention, but is not intended asa limitation thereof. The following abbreviations are employed in theexample:

    ______________________________________                                        Ph =           phenyl                                                         t-Bu =         tertiary-butyl                                                 Boc =          tert-butoxycarbonyl                                            Et =           ethyl                                                          h =            hour(s)                                                        THF =          tetrahydrofuran                                                DMF =          dimethylformamide                                              mol =          mole(s)                                                        mmol =         millimole(s)                                                   min =          minute(s)                                                      RT =           room temperature                                               g =            gram(s)                                                        ag =           aqueous                                                        sat(sat'd) =   saturated                                                      mg =           milligram(s)                                                   TLC =          thin layer chromatography                                      EtOAc =        ethyl acetate                                                  Et.sub.2 O =   diethyl ether                                                  eq =           equivalent(s)                                                  i-PrOH =       isopropanol                                                    MeOH =         methanol                                                       n-Bu.sub.4 NI =                                                                              tetra-n-butylammonium iodide                                   DME =          1,2-dimethoxyethane                                            ______________________________________                                    

EXAMPLE Preparation of[IS-[IR*,2S*(2S*,3R*)]]-[3[[3-[[(1,1-dimethylethoxy)carbonyl]amino]-2-hydroxy-4-(4-[2-(4-morpholinyl)-2-oxo-ethoxy]phenyl]butyl]amino]-2-hydroxy-1-(phenylmethyl)propyl]carbamicacid 1,1-dimethylethyl ester (BMS-186318) ##STR32## (i) Diazomethane-Et₂O solution

To the mixture of 40% aqueous KOH (75 ml) and Et₂ O (255 ml) cooled at0° C. was added 1-methyl-3-nitro-1-nitrosoguanidine (23.85 g, 162.2mmol) portionwise. The mixture was swirled several times during eachaddition. After 10 min, the resulting yellow Et₂ O layer was decantedover KOH pellets at 0° C. and dried for 2.0 h at 0° C.

(ii) Compound 1 ##STR33##

To the solution of N-Boc-L-phenylalanine (14.34 g, 54.05 mmol) in dryTHF (80 ml) cooled at -20° C.(dry ice-CCl₄ bath) was added isobutylchloroformate (7.01 ml, 54.05 mmol) over 5 min, followed by4-methylmorpholine (5.94 ml, 54.05 mmol) and the mixture was stirred for20 min. The white precipitate was removed by filtration under argonatmosphere and washed with ca. 70 ml of dry THF. The combined THFsolution of mixed anhydride was cooled to -5° C. and poured into theabove prepared diazomethane in Et₂ O solution at 0° C. The resultingyellow solution was kept at 0° C. for 2.0 h, then RT overnight. N₂ wasthen bubbled through the light-yellow solution for 30 min, and Et₂ O(400 ml) then added. The solution was washed with H₂ O (400 ml),saturated NaHCO₃ (300 ml) and brine (300 ml), and was dried overanhydrous MgSO₄. Concentration in vacuo afforded a yellow residue, whichwas triturated with hexane to give, after drying over P₂ O₅ overnightunder high vacuum, 14.72 g (94%) of α-diazoketone 1 as a pale yellowsolid. This material was used immediately in the reaction of the nextstep without further purification.

(iii) Compound 2 ##STR34##

To the solution of the crude α-diazoketone 1 prepared above (14.72 g,50.87 mmol) in dry Et₂ O (500 ml) cooled at 0° C. was added, dropwise, asolution of 4N HCl in dioxane (12.72 ml, 50.87 mmol) while maintainingthe temperature below 5° C. The reaction mixture was then stirred at 0°C. for 1.0 h. TLC (hexane-EtOAc 4:1) showed trace amounts of thestarting α-diazoketone remained. Additional 4N HCl in dioxane (636 μl,0.05 eq., 2.54 mmol) was added and the mixture was stirred at 0° C. forone additional hour.

Concentration in vacuo gave a residue which was dissolved in hot Et₂ O(60 ml). Hexane (200 ml) was slowly added and the mixture allowed tostand for 2.0 h at 5° C. The solid was filtered and dried over P₂ O₅under high vacuum to afford 9.58 g (first crop) of α-chloroketone 2. Thefiltrate was concentrated to dryness and the residue was againrecrystallized from Et₂ O-hexane to give an additional 4.41 g (secondcrop) of α-chloroketone 2. Total yield: 13.99 g (92%).

(iv) Compound 3 ##STR35##

NaBH₄ (1.59 g; 42 mmol) was added to a solution of α-chloroketone 2prepared above (5 g; 16.8 mmol) in 84 ml of THF and 9 ml of H₂ O at 0°C. After stirring at 0° C. for 45 min the reaction mixture wasconcentrated to dryness. The residue was stirred at 0° C. with EtOAc(150 ml) and H₂ O (25 ml) while saturated KHSO₃ solution was carefullyadded until the pH was ˜1.5. This mixture was then diluted with 350 mlof EtOAc and the layers were separated. The organic layer was washedwith H₂ O (100 ml) and brine (100 ml). After drying over MgSO₄, theorganic layer was concentrated to a white solid. A portion of this solid(4.89 g) was recrystallized from 70 ml of hot EtOAc to afford 2.47 g(50%) of Compound 3 as a white solid containing a few percent of itsdiastereomer, the following Compound 4: ##STR36## (v) Compound 5##STR37##

0.71M KOH in EtOH (14.7 ml; 10.4 mmol) was added to a suspension ofCompound 3 (2.6 g; 8.67 mmol) in 87 ml of EtOH at RT. The reaction wasstirred 1.5 h at RT, during which time the thick suspension became afine powdery one. At this time, the EtOH was removed in vacuo and theresidue was partitioned between EtOAc (200 ml) and H₂ O (200 ml). Theorganic layer was washed with saturated NH₄ Cl solution (2×100 ml), H₂ O(2×100 ml), and brine (100 ml). After drying over MgSO₄, the EtOAc wasremoved in vacuo and the solid white residue was recrystallized bydissolving in 10 ml of reluxing EtOAc and adding 190 ml of hexane. Theresulting crystalline suspension was allowed to cool to -40° C. andstand overnight. Filtration, rinsing with hexane, and drying under highvacuum for two hours afforded 1.92 g (84%) of Compound 5 as a colorlesscrystalline solid. This material was 99.1% diastereomerically pure byHPLC.

(vi) Compound 6 ##STR38##

To a solution of N-Boc-0-benzyl-L-tyrosine (25.g, 67.3 mmol) in dry THF(90 ml) cooled at -20° C. was added isobutyl chloroformate (8.7 ml, 67.3mmol) followed by 4-methylmorpholine (6.8 ml, 67.30 mmol) and themixture was stirred for 20 minutes. The precipitate was filtered andwashed with dry THF. The filtrate was cooled to -5° C. and poured into adiazomethane in ether solution (prepared from1-methyl-3-nitro-1-nitrosoguanidine (29.7 g, 202 mmol) as described in(i) at 0° C. The resulting yellow solution was kept at 0° C. for 2.0 h,then at RT overnight. Nitrogen was then bubbled through the solution for30 minutes, the solution diluted with Et₂ O (500 ml) and then washedwith H₂ O, sat'd NaHCO₃, and brine, and dried (MgSO₄). Concentration invacuo afforded a yellow residue, which was triturated with hexane (500ml) to give 24.5 g (92%) of the corresponding α-diazoketone as anoff-white solid. A solution of 48% aqueous HBr (5.8 ml, 51.4 mol) wasadded dropwise to the α-diazoketone (20.3 g, 51.4 mmol) in 500 ml of1,4-dioxane-DME (2:1) cooled at -5° C. After 30 minutes, saturatedNaHCO₃ was added until pH=7.0 and the solvent was removed under reducedpressure. The mixture was diluted with H₂ O and extracted with EtOAc.The combined organic extracts were washed with H₂ O and brine and dried(Na₂ SO₄). Concentration in vacuo followed by recrystallization fromEtOAc-hexane gave 20.9 g (91%) Compound 6 as an off-white solid.

(vii) Compound 7 ##STR39##

To a solution of Compound 6 (23.3 g, 50.0 mmol) in 250 ml of MeOH-THF(1:1) cooled at -5° C. was added, portionwise, NaBH₄ (2.0 g, 50.0 mmol).After 1 hour, 10% KHSO₄ (75 ml) was added at 0° C. and the mixture wasallowed to warm to RT. The mixture was extracted with hot EtOAc and thecombined organic extracts were washed with H₂ O and brine, and dried(Na₂ SO₄). Concentration in vacuo followed by recrystallization fromEtOAc (350 ml) afforded 14.5 g (62%) of the syn bromohydrin as a whitesolid. HPLC analysis showed the diastereomeric ratio as 95:5. To asolution of the syn bromohydrin, prepared as above (115.2 g, 0.256mole), in 1.5 L of THF and 1.5 L of 100% EtOH was added a solution ofKOH (17.2 g of 87.6% pellets, 0.269 mole) in 300 ml of 100% EtOH at RT.After 15 minutes, 1 liter of saturated aqueous NH₄ Cl was added and themixture then diluted with 6 L of H₂ O to give a precipitate. The solidwas filtered, washed with H₂ O, and extracted into 1 liter of EtOAc. Theorganic phase was dried (Na₂ SO₄) and concentrated in vacuo to give asolid which was triturated with 1 liter of hexane, to afford 79.3 g(84%) of Compound Z as a white solid.

(viii) Compound 8 ##STR40##

The mixture of Compound 7 (5.0 g, 13.5 mmol) and Pd(OH)₂ (500 mg) in 100ml EtOH and 25 ml of EtOAc was stirred under hydrogen atmosphere for 4.5hours. The catalyst was removed by filtration and the filter cake waswashed with EtOH, MeOH, and EtOAc. The combined washes were concentratedin vacuo to give 3.8 g (99%) of Compound 8 as a white solid.

(ix) Compound 9 ##STR41##

NaH (48 mg, 60% dispersion in mineral oil, 1.2 mmol) was washed twicewith hexane and suspended in 1.0 ml of dry DMF. The suspension wascooled to 0° C. and a solution of Compound 8 (280 mg, 1.0 mmol) in 1.5ml of dry DMF was added. The mixture was stirred at 0° C. for 30 minutesand then 4-(2-bromoacetyl)morpholine (J. Med. Chem., 35, 1685 (1992);270 mg, 1.3 mmol) as added in one portion, followed by n-Bu₄ NI (185 mg,0.5 mmol). The resulting mixture was stirred at RT overnight. Aftercooling to 10° C., H₂ O was added and the mixture extracted with EtOAc.The combined extracts were washed with H₂ O and brine, dried (NaHCO₃)and concentrated in vacuo to give a crude product which was purified byflash chromatography (hexane-EtOAc: 1:1 to 1:4) on silica gel to give392 mg (96%) of Compound 9 as a white solid.

(x) Compound 10 ##STR42##

Compound 5 (15.0 g; 56.96 mmol) dissolved in 350 ml of EtOH was added,with stirring, over 1 h to 350 ml of concentrated NH₄ OH at 0° C. NH₃gas was bubbled through the reaction mixture during the addition and for1 hour after. The reaction was then warmed to RT and stirred overnight.The resulting slurry was diluted with 800 ml EtOAc and the organic layerwashed repeatedly with brine. The organic extracts were dried (MgSO₄)and concentrated to give a white solid which was triturated with 10%i-PrOH/EtOAc to give 4.37 g of Compound 10. The mother liquors wereevaporated and triturated again as above to give an additional 5.73 g ofCompound 10 (total yield: 10.1 g; 63%).

(xi) Compound 11 ##STR43##

A mixture of Compounds 9 (407 mg, 1.0 mmol) and 10 (280 mg, 1.0 mmol) in1.0 ml of dry DMF was heated at 100° C. for 4.0 h. Concentration invacuo followed by flash chromatography (CHCl₃ -MeOH-NH₄ OH;98:2:0.2 to95:5:0.5) on silica gel afforded 501 mg (73%) of Compound 11 as a whitesolid.

m.p. 118°-120° C.; [α]_(D) =-4.7°, [α]₃₆₅(Hg) =-23.6° (c 1.0, MeOH).Mass Spec. (FAB):687⁺ (M+H)⁺.

    ______________________________________                                        Anal. Calc. for C.sub.36 H.sub.54 N.sub.4 O.sub.9.0.30H.sub.2 O:              ______________________________________                                                 C, 62.46;     H, 7.95; N, 8.09.                                      Found:   C, 62.46;     H, 7.91; N, 8.28.                                      ______________________________________                                    

What is claimed is:
 1. A method for the prophylaxis or treatment of adisease caused by the HIV virus in a human patient, which comprisesadministering to said patient, either sequentially or concurrently, aneffective HIV-inhibiting amount of an HIV-1 protease inhibitor compoundof the formula ##STR44## or a pharmaceutically acceptable derivativethereof, and an effective HIV-inhibiting amount of one or more proteaseinhibitor compounds selected from the group consisting of (a) thecompound of the formula ##STR45## or a pharmaceutically acceptablederivative thereof, (b) the compound of the formula ##STR46## or apharmaceutically acceptable derivative thereof, (c) the compound of theformula ##STR47## or a pharmaceutically acceptable derivative thereof,(d) the compound of the formula ##STR48## or a pharmaceuticallyacceptable derivative thereof, (e) the compound of the formula ##STR49##or a pharmaceutically acceptable derivative thereof, and (f) thecompound of the formula ##STR50## or a pharmaceutically acceptablederivative thereof, and (g) the compound of the formula ##STR51## or apharmaceutically acceptable derivative thereof.
 2. The method accordingto claim 1 wherein there is employed the protease inhibitor of theformula ##STR52## or a pharmaceutically acceptable derivative thereof.3. A method of reducing or eliminating antiviral resistance resultingfrom administration to a human patient of a protease inhibitor selectedfrom the group consisting of (a) the compound of the formula ##STR53##or a pharmaceutically acceptable derivative thereof, (b) the compound ofthe formula ##STR54## or a pharmaceutically acceptable derivativethereof, (c) the compound of the formula ##STR55## or a pharmaceuticallyacceptable derivative thereof, (d) the compound of the formula ##STR56##or a pharmaceutically acceptable derivative thereof, (e) the compound ofthe formula ##STR57## or a pharmaceutically acceptable derivativethereof, (f) the compound of the formula ##STR58## or a pharmaceuticallyacceptable derivative thereof and (g) the compound of formula ##STR59##or a pharmaceutically acceptable derivative thereof, or a combination oftwo or more of said inhibitors, which comprises administering, eitherconcurrently or sequentially, an effective HIV-inhibiting amount of aprotease inhibitor having the formula ##STR60## or a pharmaceuticallyacceptable derivative thereof.
 4. The method according to claim 3wherein the protease inhibitor of formula II, or a pharmaceuticallyacceptable derivative thereof, is administered in combination with aprotease inhibitor of the formula ##STR61## or a pharmaceuticallyacceptable derivative thereof.
 5. A pharmaceutical composition forprophylaxis or treatment of a disease caused by the HIV virus comprisingan effective HIV-inhibiting amount of a protease inhibitor compound ofthe formula ##STR62## or a pharmaceutically acceptable derivativethereof and an effective HIV-inhibiting amount of one or more proteaseinhibitor compounds selected from the group consisting of (a) thecompound of the formula ##STR63## or a pharmaceutically acceptablederivative thereof, (b) the compound of the formula ##STR64## or apharmaceutically acceptable derivative thereof, (c) the compound of theformula ##STR65## or a pharmaceutically acceptable derivative thereof,(d) the compound of the formula ##STR66## or a pharmaceuticallyacceptable derivative thereof, (e) the compound of the formula ##STR67##or a pharmaceutically acceptable derivative thereof, (f) the compound ofthe formula ##STR68## or a pharmaceutically acceptable derivativethereof, and (g) the compound of the formula ##STR69## or apharmaceutically acceptable derivative thereof in combination with apharmaceutically acceptable carrier or diluent.
 6. A compositionaccording to claim 5 wherein the second protease is the compound offormula ##STR70## or a pharmaceutically acceptable derivative thereof.